Introduction
The prevalence of endoscopy-related injury (ERI) in practicing gastroenterologists
is reported to be as high as 89 % and is commonly attributed to repetitive movements,
awkward postures, procedure volume, number of years in practice, and standing for
long periods while performing endoscopy [1]. Little is known about the time of onset of ERI in gastroenterologists, as the prevalence
of ERI and risk factors for ERI in physicians in gastroenterology fellowship training
are not well established. Recent evidence suggests that ERI affects up to 49 % of
gastroenterology fellows [2]
[3]. However, these studies are limited by sample size, gender representation, and provide
minimal data about specific types of injury. Regardless of these limitations, the
staggering proportion of gastroenterology fellows reporting ERI indicates a critical
need for additional detailed information on ERI that serves as a foundation for the
development of optimal methods and timing of ergonomics training.
Endoscopy is physically demanding and requires considerable training and dexterity
to effectively perform procedures. Endoscopic ergonomics is the study of safe interaction
between the endoscopists and their work environment, namely the endoscope and the
endoscopy unit, to minimize the risk of ERI [4]. Endoscopes are only available in one size regardless of operator hand size and
strength, which requires many gastroenterologists to work out of their neutral positions,
predisposing them to ERI [5]. Though this manuscript focuses on gastroenterology, challenges with endoscopic
ergonomics is applicable to laparoscopic surgery broadly, which in turn informs endoscopic
ergonomics research and training. Literature on ergonomics in laparoscopic surgery
suggests that monitors placed at eye-level reduce neck and shoulder muscle strain
[6], optimal table height should position the laparoscopic instrument handles close
to the surgeons elbows to minimize upper arm and shoulder discomfort [7]. and intraoperative targeted stretching microbreaks lasting 1.5 to 2 minutes at
20- to 40-minute intervals throughout the case can mitigate work-related fatigue,
pain, and injury [8]. Furthermore, the use of anti-fatigue floor mats and a two-piece, rather than one-piece,
lead apron during prolonged standing for complex endoscopic procedures has shown to
decrease the risk of back and neck injuries [9].
Despite the knowledge that ergonomic strategies reduce the risk of ERI and the occurrence
of ERI in gastroenterology fellows, more than 70 % of trainees report no structured
curriculum in endoscopic ergonomics and ERI prevention [2]. The Accreditation Council for Graduate Medical Education does not require formal
training in prevention of overuse injuries during gastroenterology fellowship. Because
the health and practice longevity of gastroenterologists is paramount to providing
high-quality care to patients, it is critical that gastroenterology training programs
institute curricula to mitigate ERI, supported by training institutions and organizations,
such as gastroenterology societies.
The primary aim of this study was to identify the occurrence, contributing factors,
and types of self-reported ERI of gastroenterology fellows and compare reported injuries
between male and female trainees. Knowing which injuries are most common and the risk
factors for the injuries (e. g., gender, hand size, equipment) will inform the development
of ERI prevention curricula. The secondary aim was to evaluate the reported knowledge
and use of ergonomic strategies in the prevention of ERI in a nationally representative
sample of gastroenterology fellows.
Methods
Participants
A 38-item electronic survey was sent to 15,868 members of the American College of
Gastroenterology (ACG) as previously described [1]. We sent an additional introductory email describing the study and including a web
link to the online survey instrument (Survey Monkey, San Mateo, California, United
States) to 1,220 gastroenterology trainees who were part of the larger group. Members
who self-reported current or previous performance of endoscopy were eligible to participate.
Only respondents who identified as trainees (N = 172) were included in the reported
analyses (response rate 14.1 %). We removed additional respondents from analyses if
they reported performing endoscopy for greater than 4 years (n = 4), which indicates
they are unlikely to be trainees. The final sample size for analyses was N = 168 ([Fig. 1]). No financial compensation was provided for participation. Informed consent was
implied by response to the survey. All study procedures were approved by the ACG and
the Institutional Review Board at Wake Forest University School of Medicine.
Fig. 1 Flow diagram depicting participant selection. Survey invitations were sent to 1,220
trainee members of the American College of Gastroenterology. A total of 172 trainees
responded. Respondents who were unlikely to be trainees (i. e., reported performing
endoscopy for greater than 4 years) were removed from the sample, n = 4. The final
sample size for analyses was N = 168.
Survey
The survey included both write-in and multiple-choice responses. Questions consisted
of demographics, practice information (e. g., workload), as well as ERI characteristics,
use of preventive strategies, and injury prevention training. (Supplemental file content 1). Because the survey was designed to be relevant for all ACG members, postgraduate
year (PGY) was not queried. Year in fellowship was estimated by reported years practicing
endoscopy.
Statistical analysis
The data were analyzed using SAS Enterprise Guide 7.0 (SAS Institute Inc., Cary, North
Carolina, United States). Independent samples t-tests compared continuous outcomes
between groups. Logistic regression evaluated relationships between incidence of ERI
and ordinal or continuous data, P values for chi-square (χ2) and odds ratios (OR) are reported. Chi-square analyses evaluated differences when
both variables of interest were categorical. Fisher’s exact test was used when chi-square
cell frequencies were too low to calculate chi-square. Independent samples t-tests evaluated differences in groups with continuous outcomes. Correlations were
conducted between continuous variables. Outcomes with P < 0.05 were considered statistically significant. We have reported sample sizes for
all analyses with respective data.
Results
Sample characteristics
The gender of respondents was equally represented in this sample: Male (50.5 %) and
female (49.4 %), with a mean age of 32.27 (± 2.77) years ([Table 1]). Participants in this sample had performed endoscopy an average of 2.09 (± 0.86)
years, and 98.8 % reported currently performing endoscopy. The average body mass index
(BMI) for female fellows was significantly lower than for male fellows (22.68 ± 2.94 kg/m2 vs 25.64 ± 3.34 kg/m2, P < 0.001). Female fellows reported significantly smaller glove size than male fellows
(mode = 6.0 vs 7.5, respectively, P < 0.001). We found no differences between trainees in the number of procedures (P = 0.15) or hours spent performing procedures (P = 0.20) per week. Male fellows were more likely to report experience with interventional
endoscopy than female fellows (P = 0.04) ([Table 2]).
Table 1
Demographic characteristics of respondents (N = 168).
|
Demographics
|
Total Sample (N = 168)
|
Male (n = 85)
|
Female (n = 83)
|
P
|
|
Mean ± SD
or
N
|
Range
or
%
|
Mean ± SD
or
N
|
Range
or
%
|
Mean ± SD
or
N
|
Range
or
%
|
|
Age, years
|
32.27 ± 2.77
|
28–48
|
32.61 ± 3.12
|
28–48
|
31.93 ± 2.33
|
28–40
|
.109
|
|
|
20
|
11.9 %
|
9
|
10.6 %
|
11
|
13.3 %
|
–
|
|
|
132
|
78.6 %
|
67
|
78.8 %
|
65
|
78.3 %
|
–
|
|
|
16
|
9.5 %
|
9
|
10.6 %
|
7
|
8.4 %
|
–
|
|
Height, inches
|
67.45 ± 4.02
|
59–80
|
70.24 ± 2.80
|
65–80
|
64.56 ± 2.89
|
59–74
|
< .001
|
|
Weight, lb
|
154.45 ± 32.13
|
100–290
|
175.59 ± 24.04
|
134–290
|
132.80 ± 23.92
|
100–240
|
< .001
|
|
BMI in kg/m2
|
24.49 ± 3.47
|
17.64–45.16
|
25.64 ± 3.34
|
18.56–45.16
|
22.68 ± 2.94
|
17.64–30.16
|
< .001
|
|
Years performing endoscopy
|
2.09 ± 0.86
|
0.5–4.0
|
2.09 ± 0.92
|
0.5–4.0
|
2.08 ± 0.80
|
0.5–4.0
|
.920
|
|
|
35
|
20.8 %
|
19
|
22.3 %
|
16
|
19.2 %
|
–
|
|
|
70
|
41.7 %
|
37
|
43.5 %
|
33
|
39.8 %
|
–
|
|
|
56
|
33.3 %
|
23
|
27.0 %
|
33
|
39.8 %
|
–
|
|
|
7
|
4.2 %
|
6
|
7.2 %
|
1
|
1.2 %
|
–
|
|
Reported occurrence of ERI
|
92
|
54.8 %
|
42
|
49.4 %
|
50
|
60.2 %
|
.159
|
|
Number of reported ERIs (n = 92)
|
4.26 ± 2.38
|
1–11
|
3.93 ± 2.56
|
1–11
|
4.50 ± 2.25
|
1–9
|
.041
|
SD, standard deviation; N, full sample size; n, subsample size; ERI, endoscopy-related
injury; number of reported ERI, number of injury areas reported.
Percent is calculated by column. P values are provided from t-tests (continuous data) and chi-square (categorical) analyses comparing outcomes
by gender.
Table 2
Reported procedure volume by fellow gender (N = 168).
|
Procedures/week
|
Men (n = 85)
|
|
EGD
|
Colonoscopy
|
ERCP
|
EUS
|
Enteroscopy
|
EMR/ESD/POEM
|
Bariatric
|
Luminal Stenting
|
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
|
0
|
0
|
0.0
|
1
|
1.2
|
44
|
51.8
|
54
|
63.5
|
55
|
64.7
|
60
|
70.6
|
64
|
75.3
|
56
|
65.9
|
|
1–10
|
39
|
45.9
|
38
|
44.7
|
37
|
43.5
|
29
|
34.1
|
30
|
35.3
|
25
|
29.4
|
21
|
24.7
|
29
|
34.1
|
|
11–20
|
37
|
43.5
|
32
|
37.6
|
3
|
3.5
|
2
|
2.4
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
|
21 +
|
9
|
1.6
|
14
|
16.5
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
|
Women (n = 83)
|
|
EGD
|
Colonoscopy
|
ERCP
|
EUS
|
Enteroscopy
|
EMR/ESD/POEM
|
Bariatric
|
Luminal Stenting
|
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
|
0
|
0
|
0.0
|
0
|
0.0
|
39
|
47.0
|
45
|
54.2
|
51
|
61.4
|
47
|
56.6
|
56
|
67.5
|
50
|
60.2
|
|
1–10
|
27
|
32.5
|
28
|
33.7
|
42
|
50.6
|
37
|
44.6
|
32
|
38.6
|
35
|
42.2
|
27
|
32.5
|
33
|
39.8
|
|
11–20
|
50
|
60.2
|
50
|
60.2
|
1
|
1.2
|
1
|
1.2
|
0
|
0.0
|
1
|
1.2
|
0
|
0.0
|
0
|
0.0
|
|
21 +
|
6
|
7.2
|
5
|
6.0
|
1
|
1.2
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
EGD, esophagogastroduodenoscopy; ERCP, endoscopic retrograde cholangiopancreatography;
EUS, endoscopic ultrasonography; EMR/ESD/POEM, endoscopic mucosal resection/endoscopic
submucosal dissection/peroral endoscopic myotomy; n, subsample total/number of respondents
reporting.
ER occurrence and characteristics
More than half (54.8 %) of fellows in this sample reported ERI ([Table 1]). Of those who reported ERI, the average number of injury sites was 4.26 ± 2.4 ([Table 1]). Trainees who performed endoscopy for more years were more likely to report ERI
(P = .04) but not a greater number of ERI (P = .77). Logistic regression indicated no association between number of ERI and age
(P = .48, OR = 0.960, CI[0.51, 0.48]), BMI (P = .34, OR = 1.044, CI[0.96, 1.14]), glove size (P = .20, OR = 1.368, CI[0.85, 2.21]), number of procedures per week (P = .16, OR = 0.981, CI[0.95, 1.01]), time spent in procedures per week (P = .14, OR = 0.977, CI[0.95, 1.01]), or frequency of performing specific procedures
(i. e., colonoscopy, endoscopic mucosal resection, endoscopic retrograde cholangiopancreatography
[data not shown]).
The most common sites of reported ERI were thumb (n = 54, 58.7 %), hand/finger (n = 52,
56.5 %), and wrist (n = 44, 47.8 %). However, a relatively large proportion of respondents
also experienced ERI in neck (n = 36, 39.1 %) and lower back (n = 45, 43.5 %) ([Table 3]). The only difference in laterality of affected body area by gender was in the left
thumb, such that there was a trend for female trainees to be more likely to report
pain in the left thumb (P = .05). Notably, 65.2 % (n = 60) of respondents reported being bothered by pain from
one or more ERI outside of the work environment, though there were no gender differences.
Only 5.4 % (n = 5) of respondents with ERI reported taking time off due to ERI, and
only 2.2 % (n = 2) reported taking disability leave ([Table 4]). We report treatments used for management of ERI in [Table 5].
Table 3
Location of self-reported ERI (N = 92).
|
ERI Location
|
ERI-only subsample
(N = 92)
|
Male
(n = 42)
|
Female
(n = 50)
|
P
|
|
n
|
%
|
n
|
%
|
n
|
%
|
|
Upper extremity
|
|
|
54
|
58.7
|
20
|
47.6
|
34
|
68.0
|
.259
|
|
|
52
|
56.5
|
23
|
54.8
|
29
|
58.0
|
.906
|
|
|
20
|
21.7
|
11
|
26.2
|
9
|
18.0
|
.247
|
|
|
9
|
9.8
|
3
|
7.1
|
6
|
12.0
|
.522
|
|
|
8
|
8.7
|
4
|
9.5
|
4
|
8.0
|
.773
|
|
|
44
|
47.8
|
18
|
42.9
|
26
|
52.0
|
.630
|
|
|
17
|
18.5
|
12
|
28.6
|
5
|
10.0
|
.015
|
|
|
28
|
30.4
|
9
|
21.4
|
19
|
38.0
|
.110
|
|
Back/neck
|
|
|
36
|
39.1
|
14
|
33.3
|
22
|
44.0
|
.383
|
|
|
37
|
40.2
|
12
|
28.6
|
25
|
50.0
|
.178
|
|
|
40
|
43.5
|
14
|
33.3
|
26
|
52.0
|
.216
|
|
Lower extremity
|
|
|
8
|
8.7
|
5
|
11.9
|
3
|
6.0
|
.224
|
|
|
15
|
16.3
|
6
|
14.3
|
9
|
18.0
|
.828
|
|
|
23
|
25.0
|
10
|
23.8
|
13
|
26.0
|
.978
|
P values are reported from chi-square analyses. ERI, endoscopy-related injury; N, full
sample size; n, subsample size.
Table 4
Impact of ERI on pain outside of work place, time off work, and disability (N = 92).
|
ERI
|
N
|
Pain outside of work environment
|
Time off
|
Disability
|
|
n
|
%
|
n
|
%
|
n
|
%
|
|
Total ERI-only sample
|
92
|
60
|
65.2
|
5
|
5.4
|
2
|
2.2
|
|
Upper extremity
|
|
|
54
|
20
|
37.0
|
2
|
3.7
|
1
|
1.9
|
|
|
52
|
18
|
34.6
|
1
|
1.9
|
0
|
0.0
|
|
|
20
|
14
|
70.0
|
0
|
0.0
|
1
|
5.0
|
|
|
9
|
8
|
88.9
|
0
|
0.0
|
0
|
0.0
|
|
|
8
|
6
|
75.0
|
1
|
12.5
|
0
|
0.0
|
|
|
44
|
19
|
43.2
|
1
|
2.3
|
0
|
0.0
|
|
|
17
|
9
|
52.9
|
0
|
0.0
|
0
|
0.0
|
|
|
28
|
14
|
50.0
|
1
|
3.6
|
1
|
3.6
|
|
Back/neck
|
|
|
36
|
23
|
63.9
|
1
|
2.8
|
0
|
0.0
|
|
|
37
|
24
|
64.9
|
0
|
0.0
|
0
|
0.0
|
|
|
40
|
20
|
50.0
|
1
|
2.5
|
0
|
0.0
|
|
Lower extremity
|
|
|
8
|
4
|
50.0
|
0
|
0.0
|
0
|
0.0
|
|
|
15
|
8
|
53.3
|
0
|
0.0
|
0
|
0.0
|
|
|
23
|
11
|
47.8
|
0
|
0.0
|
1
|
4.3
|
ERI, endoscopy-related injury.
Total ERI-only sample is the total number of respondents reporting.
Pain outside is reported pain outside of the work environment.
Disability is reporting using short- or long-term disability.
Table 5
Reported ERI treatment by ERI location (N = 92).
|
ERI
|
N
|
Acupuncture/
chiropractor
|
Massage
|
Medications
|
Physical
therapy
|
Rest
|
Splinting
|
Steroid
|
Surgery
|
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
|
Thumb pain
|
54
|
0
|
0.0
|
4
|
7.4
|
2
|
3.7
|
4
|
7.4
|
10
|
18.5
|
4
|
7.4
|
1
|
1.9
|
0
|
0.0
|
|
Hand/finger pain
|
52
|
0
|
0.0
|
8
|
15.4
|
3
|
5.8
|
3
|
5.8
|
11
|
21.2
|
3
|
5.8
|
0
|
0.0
|
0
|
0.0
|
|
Hand/arm numbness
|
20
|
0
|
0.0
|
4
|
20.0
|
1
|
5.0
|
2
|
10.0
|
6
|
30.0
|
3
|
15.0
|
0
|
0.0
|
0
|
0.0
|
|
Carpal tunnel
|
9
|
0
|
0.0
|
1
|
11.1
|
2
|
22.2
|
1
|
11.1
|
3
|
33.3
|
3
|
33.3
|
0
|
0.0
|
1
|
11.1
|
|
Tendonitis
|
8
|
0
|
0.0
|
0
|
0.0
|
1
|
12.5
|
1
|
12.5
|
2
|
25.0
|
2
|
25.0
|
1
|
12.5
|
0
|
0.0
|
|
Wrist pain
|
44
|
0
|
0.0
|
4
|
9.1
|
4
|
9.1
|
3
|
6.8
|
6
|
13.6
|
2
|
4.5
|
0
|
0.0
|
0
|
0.0
|
|
Elbow pain
|
17
|
0
|
0.0
|
0
|
0.0
|
2
|
11.8
|
2
|
11.8
|
4
|
23.5
|
2
|
11.8
|
0
|
0.0
|
0
|
0.0
|
|
Shoulder pain
|
28
|
0
|
0.0
|
8
|
28.6
|
4
|
14.3
|
4
|
14.3
|
3
|
10.7
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
|
Neck pain
|
36
|
0
|
0.0
|
14
|
38.9
|
5
|
13.9
|
4
|
11.1
|
5
|
13.9
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
|
Upper back pain
|
37
|
0
|
0.0
|
14
|
37.8
|
4
|
10.8
|
2
|
5.4
|
5
|
13.5
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
|
Lower back pain
|
40
|
1
|
2.5
|
9
|
22.5
|
4
|
10.0
|
3
|
7.5
|
4
|
10.0
|
0
|
0.0
|
1
|
2.5
|
1
|
2.5
|
|
Hip pain
|
8
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
1
|
12.5
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
|
Knee pain
|
15
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
3
|
20.0
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
|
Foot pain
|
23
|
0
|
0.0
|
2
|
8.7
|
3
|
13.0
|
0
|
0.0
|
5
|
21.7
|
0
|
0.0
|
0
|
0.0
|
0
|
0.0
|
N is the number of respondents reporting injury.
n is the number of respondents reporting specific therapy by injury.
Pain outside is experiencing pain outside of the work environment.
Percentages are calculated within rows.
We found that the male and female fellows were equally likely to report the occurrence
and severity of ERI. Female fellows were more likely to report a greater number of
injury areas (4.50 ± 2.25) than male fellows (3.93 ± 2.56) (P = .04) ([Table 1]), and elbow pain was significantly more likely to be reported by male (28.6 %) than
female fellows (10.0 %) (P = .02) ([Table 3]).
ERI during pregnancy
Only five trainee respondents reported pregnancy during their fellowship. Of these
five trainees, four (80 %) reported ERI that began during pregnancy, and three reported
worsening ERI during pregnancy. All four respondents who were pregnant during fellowship
reported performing endoscopy while pregnant with no reduced caseload, and only one
reported additional allotted time for procedures during pregnancy.
Mechanisms reported to contribute to ERI
Among fellows who reported ERI, the leading causes were attributed to torqueing with
the right hand (n = 68, 73.9 %), standing in awkward positions while supporting an
endoscope (n = 57, 62 %), and standing for prolonged periods (n = 45, 48.9%). There
were no gender differences in contributing action of ERI ([Table 6]).
Table 6
Mechanism of ERI (N = 92).
|
ERI contributing action
|
ERI-only subsample
(N = 92)
|
Male
(n = 42)
|
Female
(n = 50)
|
P
|
|
N
|
%
|
n
|
%
|
n
|
%
|
|
Adjusting tip angulation with left hand
|
32
|
34.8
|
12
|
28.6
|
20
|
40.0
|
.252
|
|
Torquing with right hand
|
68
|
73.9
|
29
|
69.0
|
39
|
78.0
|
.330
|
|
Use of lead aprons
|
16
|
17.4
|
9
|
21.4
|
7
|
14.0
|
.349
|
|
Use of the elevator on the duodenoscope
|
7
|
7.6
|
4
|
9.5
|
3
|
6.0
|
.525
|
|
Standing for prolonged periods of time
|
45
|
48.9
|
19
|
45.2
|
26
|
52.0
|
.518
|
|
Standing in awkward positions supporting an endoscope
|
57
|
62.0
|
27
|
64.3
|
30
|
60.0
|
.673
|
|
Non-adjustable bed/monitor
|
24
|
26.1
|
12
|
28.6
|
12
|
24.0
|
.619
|
P values are provided from chi-square analyses.
ERI, endoscopy-related injuries.
N is the full sample size.
n is the subsample size.
Exposure to ERI prevention and ergonomics
In our cohort, 14.9 % reported no current or previous training in ERI prevention ([Table 7]). The most common ERI prevention training reported was on the importance of adjusting
the bed height (n = 114, 67.9 %), posture (n = 101, 60.1 %), and adjusting monitor
height (n = 86, 51.2 %). In our cohort, ERI was not less likely in respondents with
ERI prevention training (P = 0.35). Though less than half of the sample (n = 48, 28.6 %) reported taking breaks
(of any length), they were not associated with lower likelihood of injury (P = 0.26). The most common reported break lengths were micro breaks (n = 47, 28 %),
followed by 15– and 30-minute breaks (n = 17, 10.1 % for each) ([Table 7]).
Table 7
Reported training in ERI prevention and use of breaks (N = 168).
|
ERI prevention training
|
Total sample (N = 168)
|
|
n
|
%
|
|
Prevention training
|
|
|
101
|
60.1
|
|
|
114
|
67.9
|
|
|
86
|
51.2
|
|
|
44
|
26.2
|
|
|
15
|
8.9
|
|
|
25
|
14.9
|
|
Scheduled breaks
|
|
|
11
|
6.6
|
|
|
28
|
16.7
|
|
|
5
|
3.0
|
|
|
5
|
3.0
|
|
|
97
|
57.7
|
|
Break length
|
|
|
47
|
27.9
|
|
|
17
|
10.1
|
|
|
17
|
10.1
|
|
|
7
|
4.2
|
|
|
7
|
4.2
|
N is the full sample size
ERI, endoscopy-related injury.
n is the number reporting.
Discussion
In this national sample of gastroenterology trainees, over half of respondents reported
at least one area affected by ERI. There were no significant gender differences in
the reported occurrence or severity of ERI, though our data indicate emergence of
ERI with an onset as early as less than one year performing endoscopy, with increasing
occurrence over time. A recent survey in practicing Japanese endoscopists showed longer
upper and lower endoscopic submucosal dissections and lower gastrointestinal treatment
were significantly associated with low back musculoskeletal disorders [10]. However, there were gender differences on specific ERI outcomes, such that females
reported a greater number of injury areas, and males were more likely to report elbow
pain, which mirrors the findings in a recently published large, non-trainee sample
of practicing gastroenterologists [1]. Overall, our results suggest that specific vulnerabilities to ERI emerge as early
as training and should be both monitored and prevented.
Our findings differ from a study published in 2008 that indicated early career gastroenterologists
(in practice < 39 months) reported different locations of pain compared to more experienced
practitioners [11]. These differences may be due to variability in measurement, sample, or reflect
differences in skill already apparent post-fellowship, but not developed to the extent
of more experienced practitioners.
In contrast, the proportion of reported ERI location in our study are similar to a
recent survey in practicing gastroenterology [1]. In this study of practicing gastroenterology, the most common sites of ERI were
thumb (59 %), hand/finger (56.5 %), and wrist (48 %), which are reflected in the present
sample and suggests early vulnerability to injury in certain locations due to overuse
causing strain and soft tissue microtrauma.
Ergonomically inappropriate instruments are a major ERI consideration among gastroenterology
physician researchers as well as laparoscopic researchers generally. A prevalent hypothesis
is that practitioners with smaller hand size, specifically women, may have more difficulty
using the instruments, which will then lead to ERI. In addition to smaller hand size,
this could also be attributed to suboptimal grip strength, reduced force generating
mass [12]
[13]
[14], as well as ergonomically inappropriate instruments [5]. Though not statistically significant, we found greater proportions of female trainees
reporting upper extremity ERI, and there was a significant trend indicating that females
were more likely to report left thumb pain compared to male fellows. This may not
have reached significance in our sample due to sample size and the overwhelming reports
of ERI generally. This is congruent with a study that indicated that female gastroenterology
fellows were more likely to report that their hand size (97.4 % of whom had glove
size of 6.5 or less) was too small for a standard endoscope [14]. Despite this, only 34.2 % of respondents indicated that they would opt to use smaller
instruments if given the option [14]. Regardless of the research focus to evaluate differences between men and women,
this suggests that development of ergonomics curricula, instruments, or other innovations
that consider and accommodate variability in characteristics such as hand size and
grip strength is critical to preventing ERI among gastroenterology.
Our finding that male gastroenterologists were more likely to report elbow pain due
to ERI is noteworthy because this outcome was not affected by pre-existing (non-ERI)
injury and has been reported in a larger non-trainee sample [1]. Male endoscopists should be cognizant that elbow pain appears to be a specific
vulnerability and determine forces contributing to it and ensure measures are instituted
to avoid it. Specific to female gastroenterology fellows in this sample, 80 % who
had a pregnancy during training reported ERI, with most (75 %) reporting worsening
pain. Though our sample size is small, these proportions are congruent with recent
findings in non-trainee female gastroenterology [1]. As the number of female physicians entering gastroenterology grows, the impact
of endoscopy during pregnancy and determining ways to prevent injury will be important
issues to address.
Our results diverge from a recent survey [2] of 165 trainees (35.2 % females) in which female gastroenterology fellows reported
a higher rate of ERI. There are several explanations for this discrepancy, including
differences in the number of females in each cohort and question verbiage. In addition,
previously described risk factors for ERI [15] including procedure volume ( > 20 cases/week) and greater number of hours spent
performing endoscopy ( > 16 hours/week) were not associated with ERI in our sample.
However, congruent with this research, we found the occurrence of reported ERI increased
after the first year of training. It is likely that younger age and less cumulative
procedure burden explains the disparities.
The need for more substantial training in ergonomics for trainees is apparent in the
high rate of reported ERI as early as fellowship. Comparisons have been made between
gastroenterology trainees and novice endurance runners. Like these runners, gastroenterology
trainees repeatedly employ postures and repetitive and kinetic muscle forces for holding
and advancing an endoscope in ways that are largely unfamiliar. One study evaluating
the rate of injuries in novice runners found that those who increased their weekly
running distance by more than 30 % over a 2-week period sustained more overuse injuries
compared to those who increased their distance by less than 10 % [16]. Though data suggest that gradually increasing physical activity by 10 % or less
per week may reduce injury risk, this has not been evaluated in gastroenterology trainees
regarding endoscopy volume [17]. Identifying the optimal increase in physical activity will be key as the field
moves toward competency-based assessment. It will also be critical to have competent
trainers that teach proper ergonomic principles of scope handling techniques [18]. This training is further important because endoscopy is highly repetitive, which
can develop into muscle memory is that is difficult to correct. Adopting proper technique
is crucial in early training phases and may protect against ERI and potential disability.
Despite the high rate of occurrence of ERI among fellows, the exposure to and benefit
of ergonomics training is mixed. Most (85.1 %) gastroenterology fellows in our sample
reported receiving some form ergonomic training, but no relation was found between
ergonomics training and occurrence of ERI. However, these results differ from a 2019
survey [3] in which 36 % of gastroenterology fellows had ergonomics training. Further, ERI
was less prevalent in fellows who had attended ergonomics training than in those who
had not, suggesting a beneficial effect. When comparing the present trainee sample
to a recent non-trainee sample [1], it appears that ergonomics training has become more common, which is encouraging
(61.5 % of gastroenterologists vs 85.1 % of trainees). This may be due to increasing
awareness of risks for ERI coupled with a call from gastroenterology societies for
an increased focus on ergonomics [18]
[19]. Nonetheless, the large number of gastroenterology trainees reporting ERI indicates
an opportunity for improvement in ergonomic training and instrument design. To that
end, ASGE has recently published a core curriculum for ergonomics in endoscopy for
trainers and trainees that outlines cognitive, technical, and non-technical skills
that should be obtained for endoscopy [20].
Recent research has started to shed light on pathophysiology mechanisms of ERI and
best practices in ergonomic education. In a study evaluating biomechanical risk factors
during colonoscopy, the activity of the left-wrist extensors, left thumb extensors,
and right-wrist extensors exceeded the hand activity level action limit established
by the American Conference of Industrial Hygienists during routine colonoscopy resulting
in injury [21]. Another study assessed the impact of simulation-based ergonomic training curriculum
(i. e., didactic lectures, watching videos of expert performance, ergonomic-specific
feedback, and an ergonomics checklist to augment feedback) and found it to be associated
with a lower rate of ERI [22]. However, despite this training, the intervention group was still at moderate risk
for ERI, which highlights the need for multimodal ergonomic training and intervention,
such as the creation of adjustable or ergonomically appropriate instruments [22]
[23]. A pilot study involving individual assessment and instruction by a physical therapist
resulted in improvement of musculoskeletal complaints among endoscopists reporting
ERI [24].
There are several strengths and limitations to consider in this study. Though the
sample size is small, it is one of the largest gastroenterology trainee samples with
a near-equal distribution between male and female gastroenterology ([Table 8]), which allows for meaningful gender comparisons. Notably, there is a potential
for response bias, as only 14.1 % of gastroenterology trainees completed the survey.
However, this is comparable to other published samples [2]
[3]. Other limitations are inherently related to the self-reported survey design, including
selection and recall bias [25].
Table 8
Published reported occurrence of ERI in gastroenterology fellows.
|
Study
|
Year of survey
|
Year of publication
|
Sample size
|
% male
|
% female
|
% reporting ERI
|
|
Villa et al.[3]
|
6/2016; 5/2017
|
2019
|
156
|
65
|
35
|
47
|
|
Austin et al.[2]
|
3/2016–7/2016
|
2019
|
165
|
65
|
35
|
20
|
|
Morais et al. [26]
|
5/2019
|
2020
|
38
|
Not reported
|
Not reported
|
21
|
|
Pawa et al.
(current study)
|
10/2018–4/2019
|
2022
|
168
|
51
|
49
|
55
|
ERI, endoscopy-related injury.
The survey was also developed for the purpose of determining general occurrence of
ERI within this population and this study did not include a validated measure of musculoskeletal
injury. Finally, this sample of fellows was drawn from a larger sample of practicing
gastroenterologists [1]. Because of this, some fellow-specific information was not asked (e. g., postgraduate
year); therefore, this variable was estimated by number of years performing endoscopy,
which is ultimately a more precise measure of time contributing to overuse injuries.
Conclusions
Overall, our results contribute additional evidence that ERI is common in gastroenterologists
as early as fellowship training. Our outcomes provide support for three specific actions.
First, we need granularity regarding what contributes to ERI in endoscopists, during
training and beyond. Research will be required to inform what should be targeted (e. g.,
specific ergonomic techniques, other safety measures) and the optimal time for implementation
(e. g., during fellowship, throughout career). Second, it is highly likely that a
nationwide ergonomic-specific training curriculum would be highly beneficial to trainees.
However, knowledge about the most effective teaching strategies to ensure compliance
and injury prevention is needed. We suggest these should include self-assessment,
formal assessment, setting metrics and potential graded observations during endoscopy.
Finally, improvements in endoscopic instrument design safe for both male and female
gastroenterologists is paramount. This will require collaborative efforts to both
evaluate ergonomics and kinematics and design instruments around these findings.
